Author Archive

Overview

People from refugee backgrounds, including people seeking asylum, vary in their readiness to disclose previous trauma, and much depends on context, and the empathy, warmth and skill of the clinician. Talking about past experiences can may be psychologically beneficial in the right circumstances. However, the knowledge that the patient may have endured certain experiences due to their country of origin or transit is generally sufficient for you to orient your care.

Common psychological effects of torture or other traumatic events include a range of symptoms and behavioural effects. Some patients may suffer a mental health disorder, the most frequent being post-traumatic stress disorder, depressive disorder and anxiety disorders.1

impact on physical health from factors such as poor appetite and sleep issues.

Children and adolescents experience similar psychological reactions to trauma as adults, however, the clinical presentation reflects their age and development. Presentations may include behavioural issues, sleep concerns, attention difficulties, low self-esteem, friendship difficulties, enuresis, and developmental/education concerns, as well as symptoms of anxiety, depression and post-traumatic stress disorder (PTSD). Parent mental illness affects child wellbeing, and addressing both parent and child mental health is important.

Approach to care

More detail of someone’s experiences is often required to understand and manage the causes of persistent psychological and psychosomatic symptoms. Details of past traumatic experiences are best elicited if:

a trusting relationship has developed

there is adequate time for the patient to respond

the patient feels comfortable with the professional interpreter, and their confidentiality has been assured.

Some useful questions include:

‘Some people have had bad things happen to themselves and their families. Has anything happened to you or your family that could be affecting your health or the way you are feeling now?’

‘When did the problem start? You do not need to tell me all the details, but can you tell me something of what was happening at the time?’

‘Do you have any other problems that we have not talked about that I can help you with today?’

Responding to a disclosure of torture or trauma

Validate your patient’s reaction by acknowledging their experience (e.g. ‘That’s a terrible thing you have been through.’).

Remind your patient that their reaction is a normal response to their circumstances, as often survivors blame themselves and see their reactions as abnormal or weak.

Avoid false assurances. Nevertheless, indicate that with time and appropriate support, improvement can be achieved.

Expect that the patient who has disclosed a traumatic event may be unwilling to talk about it in subsequent consultations. Rather than pushing them to do so, talk about other things that may be currently troubling them.

Expect inconsistencies and/or fragmented accounts in the patient’s retelling of their trauma history.

Explain to the patient how you are able to assist them.

Management

There is a consensus among practitioners experienced in caring for people from refugee backgrounds that optimum treatment of psychological problems involves non-pharmacological approaches either in addition to medication or as the primary treatment modality.2

Medication may be required to manage symptoms that are sufficiently severe that they interfere with the patient’s functioning.

When a patient presents with persistent symptoms believed to be related to trauma, consider referral to a psychiatrist, psychologist or the specialist service for survivors of trauma and torture in your state or territory

Each state and territory has a specialised torture and trauma counselling service for people from refugee backgrounds. These free and confidential services are non-denominational, politically neutral and non-aligned. For more information regarding specialist services for survivors of torture and trauma see Forum of Australian Services for Survivors of Torture and Trauma (FASSTT).

In some areas, counselling services through community health centres or mental health nurses may be available to assist the client and facilitate other referrals. See State and territory referrals.

Practice tips

Explain to the patient your diagnosis or opinion of their condition, and the likely causes of the condition. The patient’s explanation for their problem is useful to enquire about.

Be aware of the stigma attached to psychological conditions.

Outline treatment options so that the patient is able to make a choice. Be specific about what the alternatives are.

Arrange emergency psychiatric management in the usual way for patients at risk of serious mental health deterioration, suicide, and violence to others or self-harm.

Ensure that professional interpreting services are available if required.

Considerations

Somatic complaints

It is not uncommon for patients from refugee backgrounds to somatise their psychological stress. Consider the following:

Take presenting concerns seriously, and conduct appropriate examinations and investigations as needed. People from refugee backgrounds may have received inadequate health care and usually need explanations of investigations. See Approach to consultation and management.

It may be helpful to discuss the relationship between the body and mind.

If somatic symptoms persist and a link between such symptoms and emotional distress is made, consider a referral for counselling and support.

Consider the trauma basis for symptoms and refer accordingly. Specialist services for survivors of trauma and torture are located in each state and territory. See State and territory referrals or FASSTT.

Mental health of people seeking asylum

The psychological implications of uncertain migration status

People seeking asylum face particular stresses owing to their uncertain migration status, limitations on their access to benefits and, in some cases, their experiences in immigration detention centres.3 Research indicates that people seeking asylum are vulnerable to being retraumatised and have particularly poor physical and mental health.4

Issues faced by people seeking asylum include:

a limited capacity to plan for their future and develop stable social connections

detention centre experiences that may compound a sense of injustice and loss of control, and serve as reminders of persecutory practices in countries of origin

perceptions that they are not being believed by the Australian Government, or that they are being treated in a discriminatory fashion

feelings of powerlessness resulting from the limited control over their lives

exposure to unsympathetic or hostile attitudes in the media and the wider community

no or uncertain access to family reunion provisions. See Asylum seekers.

anxiety about the safety of loved ones still in dangerous circumstances overseas

limitations on their access to the resources required for positive mental health (e.g. English language tuition, secure housing)

stressors on families, including concern for wellbeing of children

the need to overcome barriers to participation in the Protection Visa application process, such as poor mental health and effects of torture or other traumatic events.

Chris Lemoh, Marion Bailes, David Isaacs

Recommendations

Offer HIV testing to all people aged ≥15 years, as prior negative tests do not exclude the
possibility of subsequent acquisition of HIV.

Routine HIV screening of children <15 years is not warranted except in unaccompanied or
separated minors. Screening should also be completed in children <15 years where risk factors or potentially associated conditions have been identified (see text).

+ Overview

HIV remains an infection of global importance. In 2013, there were approximately 2.1 million new infections, including 240,000 children, and around 1.5 million people died of Acquired Immune Deficiency Syndrome (AIDS)-related causes. New HIV infections have been declining globally since 2001, but HIV epidemiology is dynamic. The region with the largest number of people living with HIV is still Sub-Saharan Africa, where adult HIV prevalence in several countries remains high.79,80

Australia has a relatively small HIV disease burden, with fewer than 27,000 people living with HIV, and 1,200 new HIV infections diagnosed annually, including approximately 200 cases previously diagnosed overseas. Around half of the people diagnosed with HIV in Australia each year are born overseas. The highest rates of HIV diagnosis are amongst people born in Sub-Saharan Africa and South East Asia These regions are also over-represented amongst heterosexually acquired cases of HIV and late HIV diagnoses.81–84

Currently available HIV treatments are not curative, but can suppress viral replication and
prevent immunological deterioration, achieving near-normal life expectancy.85

Delayed diagnosis of HIV leads to missed opportunities for prevention through behaviour
modification to reduce the risk of transmission. Delayed diagnosis also means delayed treatment. Early treatment gives better health outcomes, and is now seen as another important strategy to reduce transmission risk.82,86–91

Australian HIV testing guidelines recommend diagnostic testing when HIV infection is clinically suspected, including in people with opportunistic infections such as TB. Guidelines also recommend offering an HIV test to people with demographic or epidemiological risk factors for HIV exposure (such as history of sex between men or being born in or having travelled to a high-prevalence country); people diagnosed with another STI or blood-borne infection; and people with a history of events indicating risk of sexual or blood-borne infection. HIV tests are also recommended for all pregnant women.92

Historically, many of the regions from which people flee persecution are also regions of high HIV prevalence, such as Sub-Saharan Africa and South East Asia. Australian immigration policy requires HIV testing of all permanent visa applicants aged 15 years and older, including those applying for humanitarian (refugee) visas. Negative tests done prior to migration do not exclude the possibility of subsequent acquisition of HIV before migration to Australia, particularly in high prevalence regions.

People who have arrived as asylum seekers may also have been exposed to HIV in source or transit countries, including during incarceration or through sexual relationships with members of sub-populations with high HIV prevalence, such as people who inject drugs and sex workers.80Asylum seekers in detention undergo screening for blood-borne viruses (in children this screening has been in place since mid 2014). Asylum seekers arriving by plane may not have had previous HIV testing, although an Immigrant Medical Examination (IME) (including screening for bloodborne viruses in those aged 15 years and older) is required if they are granted a substantive visa.

The prevalence of HIV in people from refugee-like backgrounds arriving in Australia is low and the pre-test probability of an HIV infection in a pre-screened individual from a low-prevalence country is minimal.39,41,43,48 Other guidelines have therefore suggested limiting re-testing to people from high-prevalence countries,93 in particular those from Sub-Saharan Africa, and there were different opinions within the EAG regarding this recommendation. However, given the possibility of HIV acquisition in the interval between pre-departure testing and arrival in Australia, the serious consequences of delayed diagnosis after migration for individual and public health, and that risk behaviours may be difficult to identify when consulting with a new arrival,41,93–95 the EAG recommends offering an HIV test to all people aged 15 years and over. Screening should also be completed in children <15 years where maternal status is unknown, in unaccompanied minors, if risk factors or potentially associated conditions have been identified.

+ History and Examination

Primary HIV infection may be asymptomatic, but is usually accompanied by a self-limiting illness producing infectious mononucleosis-like symptoms: fever, rash and generalised lymphadenopathy. Following primary infection, an asymptomatic phase lasts a median of 5 years before advanced immunodeficiency occurs, leading to the development of opportunistic infections and unusual malignancies associated with AIDS.96

+ Investigations

If a decision is made to offer HIV testing, obtaining informed consent is essential. In brief, the
practitioner offering the test needs to ensure that the patient understands: what HIV infection is and how HIV is transmitted; the benefits of knowing their HIV status; the availability of effective treatment and support in the event of a positive diagnosis; and that patient privacy and confidentiality regarding testing and results will be protected.92 The patient has the right to decline testing. The practitioner should request ‘HIV serology’ on the pathology request form. The initial test performed by the laboratory will be a combined HIV antibody/p24 antigen enzyme-linked immunosorbent assay (ELISA) test. As with all serological tests, a ‘window period’ exists during which a person infected with HIV may return a negative or indeterminate test. However, the window period for current testing kits has narrowed to two to three weeks after infection, and almost all people tested will have seroconverted within six weeks after infection. If the initial ELISA is positive, the laboratory performs a confirmatory Western blot. The Australian HIV testing policy currently recommends a three-month window period.92

+ Management and Referral

If HIV serology is performed and is negative, a brief post-test discussion should cover the ongoing importance of safe sex, both in Australia (with a reminder that HIV occurs in Australia) and if travelling overseas.

If HIV positive, a post-test discussion should cover: the good prognosis on treatment, patient
confidentiality, partner notification, and contact tracing. Referral to specialist services is important, including referral to culturally appropriate peer support organisations. Depending on the state and territory, HIV treating doctors may be ID or immunology physicians, sexual health specialists or a GP with S100 prescribing privileges (see links). Consider referring for counselling and psychosocial support.

It is now recommended that all people diagnosed with HIV should be offered treatment once the diagnosis is confirmed.97 Treatment of HIV infection requires combination therapy with multiple antiretroviral drugs, which suppress viral replication, and enable immune recovery. There is greater urgency to initiate treatment at lower CD4 counts. Treatment is urgent at a CD4 count ≤200 cells/μL or below, or at the diagnosis of an opportunistic infection or other ‘AIDS-defining illness’, since the median survival without treatment is around 18 months.98 At this level of CD4 count, prophylaxis against opportunistic infections may also be required.99

+ Follow Up

HIV infection is a chronic illness. Successful management requires patient empowerment and a holistic approach to long-term health and wellbeing.100 Adherence to antiretroviral treatment is of critical importance, but must be managed in the context of other physical and psychosocial conditions that both impact upon and are affected by, HIV infection and its treatment.

Immunisation in people with HIV

As with all people from refugee-like backgrounds, catch-up vaccinations are essential, unless
there is a record of previous immunisation. However, live vaccinations such as MMR or varicella should not be administered if the CD4 count is ≤200 cells/μL. The timing of such vaccinations should be discussed with the HIV care provider. Those who are not immune to hepatitis B require a higher dose of hepatitis B vaccination to achieve immunity: four double doses at 0, 1, 2 and 6 months (for adults, two normal adult doses of 20 μg, i.e. 40 μg on each visit; for children, a single adult dose of 20 μg on each visit).

Immunocompromised HIV patients who receive influenza vaccine for the first time should receive 2 vaccine doses, at least 4 weeks apart, and 1 dose annually thereafter.101 Pneumococcal vaccine is also recommended.101–103

+ Considerations in Pregnancy and for Children

Prevention of mother-to-child transmission

It is important for health workers caring for women living with HIV to initiate discussion about family planning and reproductive health early in the therapeutic relationship.104
The rate of HIV transmission from mother to child in the absence of treatment is approximately 25%, occurring mainly at delivery or via breastfeeding.105 A mother on effective HIV treatment with an undetectable viral load in pregnancy has a transmission risk to her infant of less than 0.1%.106 Also, effective combination therapy can suppress viral replication to a degree where breastfeeding is no longer contra-indicated.104

Diagnosis in infants and children

HIV infection may be diagnosed in newborn children using PCR. If HIV is not detected in the
infant’s blood by PCR, this effectively excludes HIV infection.106 However, maternal HIV
antibodies may be detectable for up to 18 months in the blood of an infant born to a mother
living with HIV, even in the absence of infant HIV infection. In infants born to women with HIV, serology should be performed at 18 months to confirm the infant is truly uninfected.

HIV-infected infants and children may present with failure to thrive or with opportunistic infections such as TB or Pneumocystis jiroveci pneumonia. Australian migration regulations do not require HIV testing for refugees and other immigrants aged under 15 years, unless specific risk factors are present, they are unaccompanied minors, or the child is migrating for adoption by an Australian citizen.18,83 This is reasonable, given that young children are unlikely to acquire HIV infection in the absence of maternal HIV infection or medical procedures early in life. Risks of sexual acquisition in older children exist if there is a history of sexual activity (which may also occur in children in the context of sexual abuse or sexual violence). Therefore, we recommend screening of infants and young children for HIV if individual risk factors are identified through history/testing or if there is identification of another condition (such as STI, active TB or an opportunistic infection).45Unaccompanied or separated children should also be screened for HIV.

Antiretroviral therapy in children

Timely diagnosis of paediatric HIV infection is important, as infants may experience rapid disease progression and develop serious opportunistic infections in a shorter timeframe than adults. However, with effective treatment, children acquiring HIV at or soon after birth may expect to grow to a healthy adulthood. Specialist paediatric HIV services exist in all states and territories.

“The way the doctor treats you personally is half the medicine…” Community consultation participant, QLD

Key points

Person-centred care principles are useful to understand each individual’s background and current needs.

A universal precautions approach to pre-migration trauma is recommended when caring for people from refugee backgrounds, including people seeking asylum.

Consider health literacy and cultural factors in the delivery of health care.

Overview

Consider the impact of past trauma on the consultation when caring for people from refugee backgrounds.

Pre and post migration trauma may have an impact on people’s clinical presentations, their experience of the consultation and their ability to participate in management of their health concerns.

Communication difficulties may be further complicated by cultural and religious differences and a lack of familiarity with the Australian healthcare system.

Use person-centred care principles to build a relationship of trust and to understand each individual’s needs.

Trauma-informed approach to care

For some people from refugee backgrounds, particularly those experiencing psychological effects of torture or other traumatic events, the consultation may be a source of anxiety.

People from refugee backgrounds may have a distrust of authority figures, among them medical professionals.1,2 Humanitarian entrants, and people seeking asylum in particular, may mistakenly hold fears of deportation if they are found to have a serious health problem.

Symptoms such as memory loss, confusion, poor concentration and self-blame may affect the patient’s capacity to hear and understand instructions and to provide information to the doctor, nurse or other healthcare provider. Intrusive memories may be triggered in the course of the consultation.

Consultation

Conveying a sense of warmth and personal interest without rushing helps to build a therapeutic relationship.

Explain and emphasise patient confidentiality, patient consent, choice and control, and that this applies to all healthcare providers, settlement workers and professional interpreters.

Review previous records in detail where possible. For example there may be an existing refugee health nursing assessment that includes information about the person’s journey, including trauma experiences. This helps avoid asking repetitive questions and the need for the patient to repeatedly relay traumatic material.

Be aware that the clinical setting and aspects of the consultation may be reminders of past trauma (e.g. being made to wait, sudden movements, medical instruments).

Explain why certain questions are necessary.

Consider deferring sensitive questions and procedures such as mental health screening and sexual health until trust is established and there is sufficient time.

Understand that patient fear and hostility are responses to trauma and may have little to do with the consultation.

Defer invasive procedures until the process and reasons for undertaking them are fully understood.

Taking a detailed history of torture or other traumatic events is not recommended; assume your patient has had traumatic experiences based on their country of origin and journey. However, psychological and psychosomatic symptoms may persist and acknowledgement of their causes may be required for ongoing management. Consider asking about past trauma only if appropriate and there is adequate time for response.

Investigations

Informed consent is essential for all investigations. However, it is not necessary to get a detailed history of past, possibly traumatic events before offering screening.

Give clear explanations for all investigations.

Respect client confidentiality, particularly for adolescents who should be seen without their parents or carers during at least part of the consultation.

Management

Assessment and management can take place over several sessions if a gradual approach is indicated.

Provide opportunities for the patient to ask questions or seek clarification about results. For example, ‘We have spoken about many things today, do you have any questions about anything we have talked about?’

Patients may need to be actively encouraged to ask questions or seek clarification. Some will have had experiences in their country of origin or other countries where this was not encouraged by health practitioners.

Establish if there are any cultural or religious factors that need to be accommodated in your care.

Consider the diversity within cultural groups and across generations and avoid stereotyping.

Consider differences in health explanatory models between the client and health practitioner.

Use translated health information where available including internet video and audio resources and local peer health education if available.

Practice tip: Use the teach back technique to check understanding, especially when working with interpreters. Ask the patient, via interpreter if needed, to explain back to you what you have told them.

Referral

Consider seeking a specialist’s advice about whether a referral is appropriate prior to making the referral.

Travelling to a specialist or another health professional may require additional resources on behalf of the patient (e.g. cost of travel, arrangements for family or support person to travel with person).

Explain the culture and the structure of the healthcare system; the role of the GP and specialists; and the patient’s healthcare entitlements and rights, such as the right to ask for a female or male healthcare provider, right to a professional interpreter, right to a second opinion.

Christine Phillips, Josh Francis

Recommendations

Investigations for malaria should be performed on anyone who has travelled from/through an endemic malaria area within 3 months of arrival if asymptomatic, or within 12 months if symptoms of fever (regardless of any pre-departure malaria testing or treatment).

Test with both thick and thin blood films AND an antigen-based rapid diagnostic test (RDT), as RDT alone is not significantly sensitive to detect all non P.falciparum infections.

All people with malaria should be treated by, or in consultation with, a specialist ID service. Discuss diagnoses urgently with an infectious disease service. Patients with malaria may deteriorate quickly, especially children, pregnant women and those with low immunity.

Admit all patients with falciparum malaria to hospital, at least for the initial part of their treatment. Experienced clinicians may treat individuals with non-falciparum or non-severe falciparum malaria infection as outpatients if they are in a non-malaria receptive area.

+ Overview

Malaria is a mosquito-spread parasitic protozoal infection caused by the genus Plasmodium. Of the five species of human malarial parasites, Plasmodium falciparum is the most common and dangerous. One-third of malaria imported to Australia occurs in migrants coming through Papua New Guinea and India.64

Malaria is endemic in many refugee-source countries, and some transit countries (see table 2.1). All refugees to Australia from malaria-endemic regions are offered a voluntary Departure Health Check (DHC), which includes an RDT for malaria (and treatment if positive) in the 72 hours prior to departure.19 Previous issues with documentation of DHC treatment and sub-optimal anti-malarial therapy have been resolved.65 Treatment is now with WHO-recommended artemether/lumefantrine and should be documented on a health manifest that accompanies the individual. Diagnoses of malaria in people from refugee-like backgrounds have decreased since the introduction of pre-departure screening for malaria.66

A list of countries with significant malaria risk is provided in table 2.1. Detailed, up-to-date information on malaria by country is available from the Malaria Atlas Project.

Australia was declared free from endemic malaria in 1981. However, much of Australia north of latitude 19°S remains receptive to malaria, due to the presence of patent mosquito vectors (Anopheles spp.).67 This has been a constant threat to Australia’s ‘malaria-free’ status.68,69 Therefore, the detection and treatment of malaria in individuals arriving into Australia from malaria-endemic areas is of significant public health importance.

Malaria has been diagnosed in 4–10% of refugee cohorts from Sub-Saharan Africa in Australian studies,41,50,70 but is uncommon in audits of newly arrived Iraqi71 or Karen refugees.43,48 Malaria has also been diagnosed in people arriving by boat off the coast of Darwin.72 Thus, there is a rationale for re-screening people from refugee-like backgrounds from malaria-endemic areas on arrival, with enhanced vigilance for malaria in people with a febrile illness.73

+ History and examination

Malaria must be considered in any patient who has visited a malarious area and presents with a febrile illness, even months after arriving in Australia. Other symptoms of malaria include headache, nausea, chills, sweating, diarrhoea and malaise.

Severe malaria requires urgent referral to a hospital. Symptoms, signs and laboratory features of severe malaria include any degree of altered consciousness, jaundice, oliguria, severe anaemia or hypoglycaemia, parasite count >100,000/μL or >2%, or, if patient is vomiting or acidotic. Conversely, individuals with long-term acquired immunity and low-grade parasitaemia may be asymptomatic.70

+ Investigations

The ‘gold standard’ test for the diagnosis of malaria remains the thick and thin blood film examination for malaria parasites by light microscopy. A combination of blood films and RDT has relatively high sensitivity for the detection of P. falciparum infection. RDTs are frequently used in Australian laboratories to supplement blood film examination. The RDT for falciparum malaria may remain positive up to 28 days post treatment (see ‘Patients with pre-departure screening test’ below).

Mixed infections with more than one Plasmodium species are not infrequent74 and can usually be identified from the blood films. Malaria PCR is available in reference laboratories and should be considered to rule out sub-microscopic parasitaemia e.g. such as in patients who may have acquired immunity to malaria and/or in whom the efficacy of treatment given is uncertain. Some individuals can harbour sub-patent infections (i.e. blood film negative) with very low levels of detection for prolonged periods of time;75 these patients may become febrile as their immunity wanes and PCR-based testing (available in reference laboratories) may be required to exclude sub-patent infection.

If a patient has symptoms consistent with malaria but negative initial blood films and/or RDT result, repeat blood films should be performed in an attempt to demonstrate malarial parasites.74 Additional investigations in an unwell patient with malaria should be directed to detecting anaemia, acute kidney injury, abnormal liver function, hypoglycaemia or a metabolic acidosis.

+ Management and referral

Refer to table 2.2 for all management.

Plasmodium falciparum malaria

All patients with falciparum malaria should be referred urgently to a physician with experience in the management of malaria. Children with malaria should be discussed urgently with a paediatric ID physician. Children and people with low immunity who have malaria may deteriorate quickly.

Current Australian recommendations suggest that all patients with falciparum malaria should be admitted to hospital, at least for the initial part of their treatment,76 although it is possible to treat individuals with non-severe malaria infection entirely as outpatients.65,70,77 Patients with asymptomatic or uncomplicated falciparum malaria who are able to tolerate oral medication should be treated with oral artemisinin-based combination therapy (ACT).76,77 The only ACT product available in Australia at present is artemether-lumefantrine (Riamet®), which is available on authority prescription for suspected or proven falciparum infection. For further treatment guidelines refer to table 2.2. For severe malaria refer to hospital immediately and seek expert advice.

Plasmodium Vivax, Malariae or Ovale Malaria

Patients with confirmed vivax, malariae or ovale malaria (or where the parasite cannot be determined) should also have artemether-lumefantrine treatment, although this preparation is only available via the PBS for falciparum malaria and patients should be prescribed the medication via a hospital pharmacy.

Patients with severe non-falciparum malaria should be referred immediately to hospital for expert advice.

In patients with P. vivax or P. ovale infection; hypnozoite eradication therapy (or ‘radical cure’) should be attempted, to reduce the likelihood of subsequent relapses.76 Hypnozoite eradication involves a weight-based, generally two-week course of primaquine, available via application through the Special Access Scheme (SAS). Health workers should pay careful attention to adherence, and be aware of the risk of relapse. Before commencing primaquine, all patients should be screened for Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency, because of the risk of haemolysis for these patients. Primaquine is contra-indicated in patients with severe G6PD deficiency, but may be used with caution, and under supervision in those with mild deficiency.

Patients with Positive Pre-departure Screening Test

Refugees with a positive malaria result on pre-departure DHC screening are treated with a three-day course of ACT before departure, according to the protocol of the International Organization for Migration (IOM). This treatment is not monitored, and adherence should be checked with the patient (or their parents, in children). Thick and thin blood film testing after arrival is recommended. The RDT may stay positive for up to four weeks after successful treatment, so is of limited use in this situation. A negative blood film does not exclude sub-patent malaria.

A person who has tested positive at the pre-departure screen but in whom there is uncertainty regarding adherence to pre-departure treatment remains at risk of recurrent symptomatic illness, and should be retreated.

Follow-up

Patients should be assessed one month post treatment and have follow-up blood films performed to ensure that the infection has been successfully treated. Asymptomatic recrudescence and relapse can occur despite initial eradication of infection and full adherence. Artemisinin resistance has been reported in some areas of the Greater Mekong Subregion (Thailand, Vietnam, Cambodia, Laos and Myanmar (Burma))78 resulting in reduced efficacy of ACT against P. falciparum. Seek expert advice if ACT resistance is suspected.

For patients with malaria caused by P. falciparum who are being treated in malaria-receptive regions of northern Australia, a single dose of primaquine is recommended to reduce the risk of transmission to local mosquitoes (see table 2.2).

Be aware that delayed relapse for all strains of malaria can occur up to one year after leaving the endemic area. Have a low threshold for re-investigating for malaria in any person with fever.

+ Considerations in Pregnancy and Breastfeeding

Pregnant women with malaria are at increased risk for severe malaria, severe anaemia, and delivery of a low birth weight infant. Anti-malarials that are considered effective and can be used in all stages of pregnancy include atovaquone-proguanil (category B2), clindamycin (category A) and quinine sulphate (category D, but has been used safely for malaria in pregnancy).76 We recommend the combination of quinine and clindamycin for pregnant patients. Clindamycin is not subsidised on the PBS for malaria treatment. Treatment should, at least initially, be given as supervised inpatient therapy. Pregnant women with severe malaria may require treatment with intravenous artesunate (as for severe malaria in non-pregnant patients) guided by expert advice.

The above medications are contained in very low levels in breast milk, and are considered safe for infants. Breastfeeding women should receive standard doses of anti-malarial treatment recommended for all adults, with the exception of doxycycline (category D). Before taking primaquine (if required), both the infant and the mother should be tested for G6PD deficiency.

quinine sulfate 600mg (adult less than 50kg: 450mg) (child: 10mg/kg up to 600mg) orally, 8-hourly for 7 days

PLUS EITHER

doxycycline 100mg (child 8 years or older: 2mg/kg up to 100mg) orally, 12-hourly for 7 days (which can start after day 1 of quinine therapy) OR (for pregnant women or children younger than 8 years) clindamycin 300mg (child: 5mg/kg up to 300mg) orally, 8-hourly for 7 days.

For patients with malaria caused by P. falciparum (either alone or with other species) acquired from the Greater Mekong Subregion (Thailand, Vietnam, Cambodia, Laos and Myanmar (Burma)) and who respond slowly to artemether+lumefantrine (ie persisting parasitaemia after 72 hours of therapy), switch to oral quinine sulfate plus either doxycycline or clindamycin as above, for 7 days.

For patients with malaria caused by P. falciparum who are being treated in malaria-receptive regions of northern Australia, a single dose of primaquine is recommended to reduce the risk of transmission to local mosquitoes. Add: primaquine 15mg (child: 0.25mg/kg up to 15mg) orally, as a single dose.

Hypnozoite eradication therapy

First exclude G6PD deficiency in all

For P. vivax infection use concurrently: primaquine 30mg (child: 0.5mg/kg up to 30mg) orally, daily, or if nausea occurs 15mg (child: 0.25mg/kg up to 15mg) orally, 12-hourly. Treat for a minimum of 14 days or, in adults more than 70kg, until a total cumulative dose of 6mg/kg is reached

For P. ovale infection use concurrently: primaquine 15mg (child: 0.25mg/kg up to 15mg) orally, daily for 14 days If a relapse of malaria occurs despite treatment with primaquine, seek expert advice.

Aesen Thambiran, Mitchell Smith, Vanessa Clifford

Recommendations

A sexual health history should be completed sensitively, with awareness of gender issues, and with reassurance and careful explanations.

Offer an STI screen to people with a risk factor for acquiring an STI or on request (see text). Universal post-arrival screening for STIs for people from refugee-like backgrounds is not supported by current available evidence.

Syphilis serology should be offered to unaccompanied and separated children <15 years.

Children <15 years should be offered screening for other STIs including HIV and syphilis if there are clinical concerns (see text for details).

A complete STI screen includes a self-collected swab or first pass urine Nucleic Acid Amplification Test (NAAT) and consideration of throat and rectal swabs for chlamydia and gonorrhoea, and serology for syphilis, HIV and hepatitis B.

Asymptomatic patients with positive syphilis serology should be treated, unless there is documented prior treatment of treponemal infection. Treat syphilis with parenteral penicillin in consultation with a sexual health or ID unit.

Specimens for Neisseria gonorrhoea microscopy and culture should be taken before treatment is instituted. Treat gonorrhoea with ceftriaxone 500mg in 2mL of 1% lignocaine IMI, plus azithromycin 1g orally.76 Repeat NAAT and culture for test of cure of gonorrhoea two weeks after treatment.

An STI screen provides an opportunity for education about safer sex and condom use.

* Chlamydia testing is consistent with the current National STI Strategy206 and Australasian Sexual Health Alliance (ASHA) guidelines.205

+ Overview

The potential health impacts of STIs include multi-organ damage and congenital effects from syphilis, while chlamydia and gonorrhoea can cause infertility and a risk of ectopic pregnancy. Maternal gonorrhoea and chlamydia can lead to severe neonatal conjunctivitis. There are personal health and public health reasons to detect these infections in individuals regardless of background and to limit their transmission in the community.

Gender-based violence is common in women and girls in conflict zones and refugee camps,207,208 although men may also experience sexual violence, and also face barriers to disclosing this information. Once settled in Australia women may be at increased risk of sexual violence22 and sexual assaults have been reported in both onshore and offshore immigration detention centres.209,210

People may not be aware of STIs or their partners’ STI status or may be unable to negotiate a monogamous relationship with their partner and may be unaware of their risk of acquiring STIs. This can occur in any relationship, including new or longstanding relationships, where people have returned from overseas having married a new partner, and in adolescents. It is important to be aware of situations that may have led to an STI acquisition, such as sexual assault, and that these circumstances may not be disclosed. In addition, due to limited access to health education, both adolescents and adults may have poor understanding of sexual health and limited knowledge of contraception or safe sex practices.

The previous ASID guidelines recommended universal screening in adults for chlamydia and gonorrhoea;14 however, since this time, there have been more published data on STI prevalence in resettled refugee populations. Despite the apparent risks, there is a low reported prevalence of chlamydia (0.8-2.0%)43,48,159,211 and gonorrhoea (0%)43,48,159,211 infections in newly arrived refugees settling in Australia and in other developed countries.48,159,211–214 Therefore, the current available evidence does not support universal screening of newly arrived people from refugee-like backgrounds for chlamydia and gonorrhoea, and favours a risk-based approach to screening.a

Syphilis infection has a higher incidence in many parts of Africa and Asia and has been diagnosed in refugees settling in Australia (prevalence 1.5-8%).41,108 Until 2014, only a proportion of refugee applicants had syphilis screening overseas as part of their visa medical examination, which was recommended for those living in ‘camp-like conditions.’17 Routine syphilis screening is now part of the Australian immigration medical examination for humanitarian entrants aged 15 years and over.18 Additionally, asylum seekers aged 15 years and older are screened and treated for syphilis in immigration detention facilities after arrival.

a. Some members of the EAG recommended offering universal STI screening in adolescents and adult because of the sensitivities of obtaining a sexual history in people from refugee-like backgrounds, particularly at an initial visit, and the difficulties in ensuring that previous syphilis has been adequately screened and treated. However, given available prevalence data, the panel did not consider that this was indicated. Furthermore, STI testing should be performed with informed consent, and hence universal screening does not obviate the need to discuss STI risks with the patient.

+ History and Examination

Discussion of sexual health and STIs can be challenging where there is low English proficiency and low health literacy. Furthermore in some cultures, open discussions about sexuality and sexual health are discouraged and there are demarcations between men’s and women’s issues. Individuals may feel deeply embarrassed to discuss sexual health with a health practitioner. Feelings of shame, guilt and fear may decrease the likelihood of patients asking for STI testing. People who identify as lesbian, gay, bisexual, transgender or intersex (LGBTI) may be reluctant to disclose/discuss this with health providers, especially if they experienced persecution in their country of origin.

Questions about sexual health should be asked sensitively, and reassuring the patient that health professionals understand these questions may be culturally unfamiliar can be helpful. It is important to explain need for screening, obtain informed consent, clarify that results will have no impact on residency status, and that confidential treatment, care and counselling is available if needed.215 Recognise the potential sensitivities around gender differences between doctor and patient – the best advice is to ask the patient about what is acceptable to them. Pelvic examination in women should be undertaken only if clinically necessary, ensuring that the woman feels comfortable with the provider and that time has been taken to build rapport and trust. Offer a chaperone and to also consider the gender of the interpreter whether onsite or via telephone.

STIs are often asymptomatic. Women may have local symptoms such as dysuria, urethritis, vaginal discharge, pelvic pain, dyspareunia, inter-menstrual or post-coital bleeding, or they may present with sequelae such as complaints of infertility. Men may have dysuria, urethral discharge or testicular pain. Anorectal symptoms include discharge, irritation, painful defecation and disturbed bowel function. Gonorrhoea or chlamydia can also present with purulent conjunctivitis.

Syphilis is usually asymptomatic; however, symptoms can range from the chancre of primary infection, to the generalised rash of secondary syphilis, to signs of tertiary disease such as aortic pathology and neurological manifestations.

Taking a sexual history from a person from a refugee-like background is an opportunity to build trust and create a safe environment in which the person may disclose an experience of sexual violence. However, most patients will not volunteer violence, in particular if family members or friends are accompanying clients. The patient needs not only to feel assured that what will be shared will remain confidential, but also that in risking the discussion about violence, there will be resources and opportunities to obtain help for this. Interpreter confidentiality and privacy is a further issue to consider, and offering a telephone interpreter is useful to preserve anonymity.

There may be cultural pressures affecting disclosure of family violence, and additional vulnerabilities related to migration status. Asylum seekers on bridging visas and those in community detention sign a code of conduct, potentially acting as a powerful negative disincentive to disclose family violence. Consider intimate partner violence in all relationships, including for those who identify as LGBTI.

+ Investigation

People from refugee-like backgrounds should be offered individualised STI screening which takes into account past screening and risk assessment.

Individuals who have had more than one recent partner or who have recently changed partners (this may not always be volunteered).

Pregnant women.

People living with HIV.

People who inject drugs.

Sex workers, and people who are clients of sex workers.

Men who have sex with men (MSM) and those who identify as LGBTI.

Adults and adolescents with a history of being incarcerated, including in immigration detention centres.

Anyone who is interested in, or who would like an STI screen.

Woman who present opportunistically for a well women’s check or PAP smear.

Anyone disclosing a history of sexual assault or gender-based violence.

In addition any sexually active person aged 15–29 years should be offered chlamydia screening in accordance with the National STI Strategy.206

The most significant risk factor for HIV and syphilis infection in minors is maternal infection. Therefore unaccompanied or separated children should be tested for HIV and syphilis.

Tests to offer in an STI screen:

First pass urine for Chlamydia trachomatis and Neisseria gonorrhoea nucleic acid amplification test (NAAT). This is non-invasive and highly sensitive.

Self-obtained Lower Vaginal Swabs (SOLVS) is the optimal sampling method in women for Chlamydia trachomatis and Neisseria gonorrhoea. While it should be offered, this method may not be culturally acceptable to women from refugee-like backgrounds and first void urine should be offered if patient declines SOLVS. See link below for instructions on how client can self-obtain samples.205

Rectal and throat swab for NAAT if at risk of infection at those sites. Offer test to all MSM, following sexual assault (at those sites) or to anyone with symptoms suggestive of infection. Gonococcal throat infections can occur in the setting of unprotected oral sex and patients may be unaware of this risk.

Swab for microscopy, culture and sensitivity for Neisseriagonorrhoea from any site with pus.

+ Management and Referral

Syphilis

Venereal syphilis, when found through screening of asymptomatic recent arrivals, is usually late latent disease of low infectivity. Ask if there is a history of previous treatment with parenteral penicillin.

Interpretation of serological tests for treponemal infection can be quite complex. Seek advice from a sexual health or ID physician whenever there is any concern or doubt. Infection with various subspecies of Treponema can also cause yaws, bejel or pinta. As it is rarely possible to determine with certainty which type of treponemal infection has resulted in positive serology in an asymptomatic patient, such patients should always be treated, unless there is documented prior treatment of treponemal infection. Treatment is with parenteral penicillin (pregnancy category A) and is usually best done in the context of a specialised sexual health or ID unit. The sexual health service will monitor treatment response with the RPR serological test at 3, 6 and (if necessary) at 12 months.205 Note that the specific treponemal tests (e.g. TPHA) tend to remain positive lifelong, even after successful treatment.

Gonorrhoea

Wherever possible, patients with a positive NAAT test for N. gonorrhoea should have microscopy and culture of genital (cervical, vaginal, urethral) and/or throat swabs if discharge is present, and/or first pass urine, before treatment is instituted.

Treatment is generally with ceftriaxone 500mg in 2mL of 1% lignocaine IMI, plus azithromycin 1g orally as a single dose.76,205 For pharyngeal, anal or cervical infection, test of cure (NAAT) should be performed two weeks after treatment is completed.205 Microscopy and culture should also be repeated to assess for antibiotic resistance. These samples can be collected at the time of NAAT test of cure sample collection to save the patient having to return again.

Chlamydia

Current treatment is with azithromycin 1g orally as a single dose, or doxycycline 100mg orally 12 hourly for 7 days.76,205 Treat anorectal chlamydia with doxycycline 100mg orally 12 hourly for 7 days or azithromycin 1g orally as a single dose with a repeat dose a week later.205

Test of cure is not routinely recommended, except for pregnant women or those with rectal chlamydia. In these situations, NAAT should be done at least four weeks after treatment.205

Other STIs

Detailed guidance on the conditions above and on other STIs is available from the Australasian STI Management Guidelines for Use in Primary Care205 and the Australian Therapeutic Guidelines.76 Advice can also be sought from a sexual health service or physician.

Contact tracing of sexual partners (and children in the case of syphilis), where relevant and appropriate, should be discussed with the patient and attempted by the treating clinician. Seek specialist advice if unsure or in complex cases e.g. new HIV diagnosis. The Australasian Contact Tracing Manual216 offers comprehensive assistance. If working with a telephone interpreter, offer to keep your patient’s name confidential.

HIV testing should be performed in all people diagnosed with an STI (see HIV).

Regular review during therapy provides an opportunity to confirm adherence with treatment, to review contact history and to give further sexual health education. If indicated, further testing may need to be undertaken for HIV after the three-month window period (see HIV) and for other STIs at the three-month visit if not undertaken at first presentation.

Consider offering immunisation for human papilloma virus for women, girls and boys in appropriate age or risk groups (see immunisation).

Consider referral for follow up of trauma associated with a history of sexual assault or gender- based violence.

An STI screen provides an opportunity for education about safer sex and condom use. It is important to inform individuals that an STI screen is not comprehensive, infections such as herpes simplex and HPV are not routinely screened for and thus the need for barrier contraception should be emphasised to minimise future risk.

Gonorrhoea, chlamydia and syphilis are notifiable diseases.

+ Considerations in Pregnancy and Breastfeeding

Doxycycline (Pregnancy category D) should not be used in pregnancy or during breastfeeding. Azithromycin (Pregnancy category B1) can be used for treatment of chlamydia and gonorrhoea.

Syphilis detected during antenatal screening should always be managed by a specialist; treatment is with penicillin (Pregnancy category A). Infants should be referred to a paediatrician for testing and follow-up.

+ Considerations for Children and Adolescents

Although children and adolescents from refugee-like backgrounds are at risk of having experienced sexual abuse and/or assault, families rarely volunteer this information. However, if such information is disclosed, or if an STI is suspected for other reasons, e.g. vaginal discharge, genital ulcers or undiagnosed chronic lower abdominal pain, seek advice from a service experienced in managing child sexual abuse, and consider mandatory reporting obligations. Other non-STI causes of genital symptoms in girls need to be considered, including pinworm infection and, occasionally, female genital mutilation/cutting (FGM/C, see Women’s health).

Unlike adults, children under 15 years are not routinely tested for HIV as part of the pre-migration or detention screen unless they are unaccompanied or separated minors; and they are not tested for syphilis.

Adolescent sexual health is frequently missed, but should be included in a post-arrival assessment. Adolescents should be seen alone for part of the consultation once rapport is established. Explaining this is routine in the Australian healthcare system and seeking permission from both the adolescent and their parent/carers is helpful in facilitating this process. Adolescent sexual health is often approached using the HEADDS framework;217 and adolescents frequently value the opportunity to ask questions of health providers.218 This form of consultation is also an opportunity for health promotion and to improve sexual health literacy.

Most adolescents can be treated for common STIs using standard adult doses. Seek specialist advice (including for assessment of child protection issues for younger children). Child and adolescent refugees who have a positive treponemal serology result should be discussed with or referred to a paediatric ID physician. If the patient is a child and the biological mother’s treponemal test is negative, congenital syphilis can usually be excluded.

Doxycycline should not be used in children less than 8 years of age. Seek specialist advice.

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Disclaimer

The information set out in the Australian Refugee Health Practice Guide (“the Guide”) is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is the Guide exhaustive of the subject matter. Persons implementing any recommendations contained in the Guide must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. The statements or opinions that are expressed in the Guide reflect the views of the contributing authors and do not necessarily represent the views of the editors or Foundation House. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates.

Whilst the information is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices.

Accordingly, Foundation House and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in the Guide for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in the Guide and whether caused by reason of any error, negligent act, omission or misrepresentation in the information. Although every effort has been made to ensure that drug doses and other information are presented accurately in the Guide, the ultimate responsibility rests with the prescribing clinician. For detailed prescribing information or instructions on the use of any product described herein, please consult the prescribing information issued by the manufacturer.